With the so-called online insurance marketplace introduced this week under the Affordable Care Act, some consumers will have a choice of expanded dental benefits. Here in Maine, those benefits will be offered in the form of dental plans for children, and will place a limit on out-of-pocket expenses. That may be of value to some kids with significant dental disease, but as Keith Shortall reports, affordability and access remain serious issues in the state's dental health system, particularly for adults.

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Here at Pleasant Street Dental Associates in Brunswick, a routine cleaning on a pediatric patient sounds like any other. This patient either has insurance, or is paying out of pocket, because Pleasant Street doesn't accept Medicaid patients, "just because of past problems of getting the state to pay for care," says Dr. David Taft.

And Taft, a long-time subcontractor at the practice, says he's not sure whether the Affordable Care Act will increase access to dental care.

"I've seen several things about it in both the dental literature, and other things," he says, "but it's really unclear to me what the dental impact is going to be."

"The only population that's actually going to gain any benefits are children," says Dr. Jonathan Shenkin, a pediatric dentist in Augusta, who also teaches at Boston University.

Shenkin says most traditional dental plans cap the yearly amount of treatments and procedures, then shut off. He says the ACA will offer plans in Maine that do not cap such benefits once an out-of-pocket threshold - otherwise known as a deductible - is met.

"In fact, one of the plans will only have a $700 out-of-pocket maximum - everything is covered 100 percent for the rest of the year," he says. "So if you actually have a child with lots of dental disease, it would only cost you $700 out of pocket."

But $700 for many families - even those who aren't considered low income - is still a lot of money.

"Lots of Maine people don't have the resources to pay for dental care, and there are lots of places in the state where access to care is difficult because of geography, because of the distance from providers," says Barbara Leonard, vice president for programs at the Maine Health Access Foundation.

Leonard says there are a number of other factors, outside the parameters of the new marketplace, that influence dental health in rural states such as Maine. "Maine's water systems are relatively well flouridated, but it's half or fewer of Maine people who actually live in places that have water system water, so all the people in Maine who have wells need to check."

And throughout the U.S., despite advancements in dentistry, there are pockets of tradition that influence attitudes about the value of teeth in general, says Dr. James Koelbl, founding dean of the University of New England's new College of Dental Medicine. Koelbl recalls when he was a young idealist dentist practicing in a town of 300 people in northern Wisconsin.

"What caught me by surprise was the number of parents - usually the mothers, but sometimes the fathers - who brought in their 21- or 22- or 23-year-old children to the dental office, and they would say, 'It's time.' And I would say, 'Time for what?'" Koelbl says. "And in that area, and in that culture, the belief was that if you had all of your teeth extracted at the age of 22 or 23, that you would never have tooth problems again. But these were young people who really didn't have a lot of dental disease."

Koelbl says he refused to carry out those extractions. In these more modern times, says Dr. Jonathan Shenkin, Maine has actually done a good job of connecting children with dental care. But it has not done as good a job as some other states at reimbursing dentists for those services through Medicaid.

"An example is a dental sealant," Shenkin says. "And a dental sealant is probably one of the most beneficial things that can be done for a high risk child."

Keith Shortall: "This is what you put on at the age of seven on adult teeth?"

Dr. Jonathan Shenkin: "The adult first molar's really the primary tooth we're trying to place a dental sealant on, because we know from data that the adult first molar is the most decayed tooth in the mouth if nothing is done to it. And in the state of Maine we pay $16 per sealant. In Connecticut and Massachussetts they pay $41 and $40, respectively, for dental sealants. And so, from our perspective, it's basically we're losing money every time we decide to do the right thing for a child in the state of Maine."

The steps that parents can do to minimize their kids' future dental problems, says Shenkin, don't really cost much money at all. "Brushing your teeth twice a day with a flouride toothpaste, not drinking juice at an early age in a sippy cup, not going to bed with a bottle, are really basic factors of behavior that are the major contributors to disease risk in children."

As for many low-income adults in Maine, says Shenkin, the only option has been to seek treatment at free clinics, or wait until a dental crisis occurs and head to the the emergency room for treatment of pain. And Shenkin doesn't believe that the new online marketplace will offer any solutions to thatproblem.

EDITOR'S NOTE: And there was a major development in the dental arena this week in Maine - the dedication Wednesday of Maine's first dental school at the University of New England campus in Portland, which plans to offer the services of fourth-year students - or "externs" - to work in communities around the state.